Basic Information
| Provider Information | |||||||||
| NPI: | 1255569042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARIOS | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12168 MOUNT VERNON AVE UNIT 90 | ||||||||
| Address2: | |||||||||
| City: | GRAND TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923135546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516406373 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2080 S E ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924082706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093889191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95017028 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1124100383 | 05 | CA | MEDICAID |